Provider Demographics
NPI:1801225909
Name:TRI-STATE COMMUNITY HEALTH CENTER-HOSP PHYSICIANS PRACTICE
Entity Type:Organization
Organization Name:TRI-STATE COMMUNITY HEALTH CENTER-HOSP PHYSICIANS PRACTICE
Other - Org Name:TRI-STATE WOMEN'S HEALTH CENTER - HOSP PHYSICIAN PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHEIF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESHONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-678-5187
Mailing Address - Street 1:109 RAYLOC DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21750-1518
Mailing Address - Country:US
Mailing Address - Phone:301-678-5187
Mailing Address - Fax:301-678-5797
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:SUITE 550, 5TH FLR
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:301-723-3940
Practice Address - Fax:301-723-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD211849OtherMEDICARE FQHC
MDS865Medicare PIN